Physician burnout: prevention strategies

Abstract Burnout syndrome is a response to occupational stress that consists of emotional exhaustion, depersonalization, and reduced personal fulfillment. It may affect health care professionals, requiring due attention and the development of preventive mechanisms. The objective of this study was to identify possible ways to prevent the onset of burnout among physicians. A literature review was conducted in PubMed and SciELO databases. The search resulted in 16 articles on the subject, of which 11 conducted individual-focused interventions, four focused on the work environment, and one focused on both aspects. In conclusion, reducing burnout levels may benefit both physicians and patients, and conducting approaches focused on both the individual and the work environment is essential. However, further research on physician burnout prevention is needed.


OVERVIEW
The term "burnout syndrome" was first used in 1974 by Freudenberger when he noticed a decrease in enthusiasm in his work compared to previous times. He correlated the lack of stimulus originated from the lack of emotional energy with the feeling of burnout. In 1981, Maslach & Jackson described burnout syndrome as a work-related impairment of mental health that consists of emotional exhaustion, individual depersonalization and reduced personal fulfillment. Emotional exhaustion is a state in which all emotional resources are exhausted; depersonalization refers to a distant, skeptical, and negative approach to the people under one's care; and reduced personal fulfillment is related to feelings of inefficiency and negative feelings about oneself.¹ Burnout syndrome often affects those with overwhelming, high-demand jobs and those who work directly with other people, such as teachers and health care professionals. Moreover, some studies suggest a high prevalence of burnout syndrome among physicians and that 1/3 of physicians are considerably affected by burnout at some point in their careers.² Burnout syndrome among physicians has been associated with an increase in medical errors, lower patient satisfaction, prolonged recovery periods for physicians, and lower job satisfaction.³ Within this context, burnout syndrome is a health issue that may result in absence from work and sick leave, consequently leading to company expenses, complications related to employee absence, and reduced service quality and productivity.³

RISK FACTORS
According to its definition, burnout syndrome is caused by occupational exposure to stress and has a multifactorial etiology. According to Gil-Monte & Peiró (apud Moreira et al. 1 ), possible risk factors for physician burnout may be classified as facilitators or triggers. Facilitators are person-related situations that may function as predictors or inhibitors of the effect stress can have on that person (resilience, job satisfaction, fatigue, and anxiety, among others), whereas triggers are factors related to the workplace (relationship with co-workers, lack of or insufficient material to do your job properly, and demand for results, among others).¹ Loss of autonomy regarding how much time to spend with patients, treating the data and not the patient, too many rules limiting the time physicians can spend with a patient, insufficient pay, and the sense of powerlessness due to the lack of resources to treat patients properly are among possible causes of physician burnout. 4

PREVENTION
Burnout prevention programs may be individualfocused, focused on the organization of the work environment, or a combination of both. Individualfocused programs usually consist of behavioral measures aimed at coping with occupational issues through social support or different kinds of relaxation exercises.
Programs focused on the work environment, on the other hand, include changes in work procedures, task restructuring, and work evaluation and supervision aimed at decreasing job demand and increasing job control and the level of participation in decision-making. 5 Both individual-and workplace-focused interventions may reduce burnout rates. Better outcomes are believed to result from conducting both interventions simultaneously rather than separately. 6

OBJECTIVE
To identify possible interventions to prevent physician burnout.

METHODS
A literature review was conducted in PubMed and SciELO databases for articles published in the last 11 years (2009-2019). The following keywords were used: physician, burnout, prevention, prevenção, and médicos. The search retrieved 544 articles in PubMed and 35 in SciELO.
After screening of titles and abstracts, 16 articles were included in this study according to the following criteria: articles published in the last 11 years (from 2009 to 2019); in Portuguese or English; conducted with physicians; and focused on prevention methods and risk factors for burnout syndrome. Exclusion criteria were studies conducted with health professionals other than physicians, with medical students or students from other fields, and which only assessed protective and risk factors without focusing on prevention.

DISCUSSION
Most studies used the MBI to assess physician burnout. The MBI is used to assess burnout in practically any occupational setting. It consists of three dimensions: emotional exhaustion (exhaustion of emotional energy and fatigue), depersonalization (indifference toward or detachment from work), and work productivity (expectations of continuous work productivity). 23 Using a single tool to assess burnout standardizes diagnostic criteria and, consequently, allows consistent observation and comparison of results.
The present literature review clearly shows that the interventions used to reduce physician burnout levels did not have any significant results. Of 16 studies, only nine had positive results (56.25%). Of these, three performed structural changes focused on the organization of the workplace, whereas the other six conducted individual-focused actions. Importantly, of the overall 16 studies, only five conducted changes focused on the workplace, corresponding to a burnout reduction success rate of 60%. The same success rate (60%) was observed for the remaining 10 studies, which performed individual-focused changes. Only one study conducted both interventions, but there were no positive results.
The reason why only a few studies implemented changes focused on the workplace is the difficulty in changing the organizational structure of medical practice. Reduction of working hours, changes in work shifts, and the improvement of team communication are some of the changes proposed in the studies, which require a great amount of time and money for the successful implementation of a new occupational structure.
Although interventions focused on the occupational environment are difficult to implement, improving communication between physicians and other members of the health care team has been shown to reduce burnout levels. Therefore, communication in the work environment should be improved, given that the health care team had an easy-to-understand and closed communication, which was implemented as a culture in the analyzed workplace.
On the other hand, interventions focused on changes in physicians' shift schedules provided fewer positive results. Physicians continued to be subjected to an increased workload, a lack of control over their shift schedules, life and death decision-making regarding patients, and long working hours. When the method was successfully implemented, it ultimately resulted in reduced workload and working hours.
In most studies, individual-focused interventions were based on mindfulness, a methodology described by Kabat-Zinn 24 aimed at keeping one's attention focused on the present. Redirecting focus to what is happening in the present seems to be related to a reduction in self-perceived stress. 25 Therefore, mindfulness-based programs are believed to be beneficial for individuals.
All studies that used mindfulness-based interventions successfully reduced burnout levels regardless of the follow-up period. This occurred because the method promotes self-awareness, elucidates the perception of psychological discomfort, and exposes barriers in the doctor-patient relationship, which results in better decision-making. The remaining studies, which used different approaches (such as selfcare workshops, self-administered psychotherapeutic tools, and debriefing sessions), were not as successful as the studies that used mindfulness-based approaches. This is probably due to the short follow-up period in these studies.
The study using both interventions did not have significant results. The approach consisted of improving communication between members of the health care team -workplace-focused -and stress management sessions -individual-focused. Stress levels and professionals' perception of productivity improved in a short time. However, results were not positive, given that the durations of the intervention and follow-up were not sufficient to influence burnout control.
The duration of follow-up varied between studies, and each study design was structured differently. This highlights how difficult it is for systematic reviews to conduct a more careful comparison of study conclusions.
Another limitation is that only a few studies had a follow-up period longer than 6 months. Although the studies with longer follow-up had positive results, we question whether the interventions are actually efficient in the long term.

CONCLUSIONS
This literature review demonstrated the relevance of burnout syndrome among physicians, as well as the need to develop techniques for burnout reduction. In addition, besides benefiting physicians, interventions aimed at reducing burnout levels may also benefit those inserted in the occupational setting of health care professionals. Approaches focused both on the individual and the organization of the workplace are believed to be more effective at reducing burnout. However, further studies are needed to identify the best possible way to prevent the onset of burnout syndrome among physicians.

AUTHOR CONTRIBUTIONS
PGM and LIU worked on the study conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, software, visualization, writing -original draft, and writing -review & editing. FAM and MJFG worked on the study conceptualization, formal analysis, methodology, project administration, supervision, and writing -review & editing. All authors approved the final version of the manuscript and are responsible for all aspects of the study.